Comprehensive Summaries of Uppsala Dissertations from the Faculty of Social Sciences 96 _____________________________ _____________________________ Dieting and Eating Attitudes in Girls: Development and Prediction BY KLARA HALVARSSON ACTA UNIVERSITATIS UPSALIENSIS UPPSALA 2000
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Comprehensive Summaries of Uppsala Dissertationsfrom the Faculty of Social Sciences 96
Dieting and Eating Attitudes in Girls:Development and Prediction
BY
KLARA HALVARSSON
ACTA UNIVERSITATIS UPSALIENSISUPPSALA 2000
Dissertation for the Degree of Doctor of Philosophy in Caring Sciences presented at UppsalaUniversity in 2000.
ABSTRACT
Halvarsson, K. 2000. Dieting and Eating Attitudes in Girls: Development and Prediction.Acta Universitatis Upsaliensis. Comprehensive Summaries of Uppsala Dissertations from theFaculty of Social Sciences 96. 60 pp. UPPSALA. ISBN 91-554-4864-X.
The aims of the present thesis were to study: 1. reported eating attitudes, dieting behavior and
body image over a 1-year period among preadolescent girls (age 7-8); 2. differences in eating
attitudes and coping between groups of teenage girls differing in dieting frequency, and to
assess changes with increasing age (age 13-17); and 3. to what extent eating attitudes, self-
esteem and coping predict disturbed eating attitudes. A final aim was to explore differences in
the reported wish to be thinner, dieting, and eating attitudes between two age-matched cohorts
of girls in 1995 and 1999 (7-15 years).
The project is designed as a longitudinal prospective study, spanning seven
years. 1300 girls in the ages (1995) 7, 9, 11, 13 and 15 years have been assessed annually for
three consecutive years (1995-1997) (Main Cohort). An additional group matched for age
with the original group was recruited in 1999 (Societal Cohort). The results suggest that
dieting and the wish to be thinner starts as early as at 7 years of age, and that repeated dieting
attempts correlate with disturbed eating attitudes. A marked increase of the wish to be thinner
was evident in the 10- to 14-year age range, and significant increases in dieting attempts
occurred mainly between ages 9 and 13. There were no differences between 1995 (Main
Cohort) and 1999 (Societal Cohort) (except among 7 and 11-year-olds) with regard to dieting,
the wish to be thinner and disturbed eating attitudes. Eating patterns and attitudes were shown
to be the strongest predictors of disturbed eating attitudes three years later. Assessment of
dieting, the wish to be thinner and eating attitudes is suggested as a component in school
health care.
Klara Halvarsson, Department of Public Health and Caring Sciences, Section for Caring
Sciences, Uppsala University, Uppsala Science Park, SE-751 83 Uppsala, Sweden
Klara Halvarsson 2000
ISSN 0282-7492
ISBN 91-554-4864-X
Printed in Sweden by Tryck & Medier, Uppsala 2000
To STAFFAN
ORIGINAL PUBLICATIONS
This thesis is based on the following papers, which are referred to in the text by their Romannumerals.
I. Halvarsson, K., Lunner, K., & Sjödén, P-O. (2000). Assessment of eatingbehaviours and attitudes to eating, dieting and body image in pre-adolescentSwedish girls: a one-year follow-up. Acta Pædiatrica, 89,996-1000.
II. Halvarsson, K., Lunner, K., & Sjödén, P-O. Development of a Swedish versionof the Adolescent coping orientation for problem expreiences (A-Cope).Scandinavian Journal of Psychology, Accepted for publication.
III. Halvarsson, K., Lunner, K., Westerberg, J., & Sjödén, P-O. Dieting, eatingattitudes and coping among Swedish adolescent girls: Changes over 3 years.Submitted for publication.
IV. Halvarsson, K., Lunner, K., Westerberg, J., & Sjödén, P-O. Prediction ofdisturbed eating attitudes in adolescent girls: A 3-year longitudinal study ofeating patterns, self-esteem and coping. Submitted for publication.
V. Halvarsson, K., Lunner, K., Westerberg, J., Anteson, F., & Sjödén, P-O. Alongitudinal study of the development of dieting among 7-17 year-old Swedishgirls. Submitted for publication
Reprints were made with the permission of the publishers.
Dieting, eating attitudes and eating disorders in women ....................................................... 7Adjustment and problem behaviors in childhood and adolescence ....................................... 9Terminology used in the present study ................................................................................ 10Dieting and eating attitudes in children and adolescents ..................................................... 10Coping.................................................................................................................................. 12Self-esteem........................................................................................................................... 13Risk factors related to the development of eating problems and eating disorders............... 14
Protective factors related to eating problems....................................................................... 20Coping............................................................................................................................ 20Self-esteem....................................................................................................................... 20Family and peers .............................................................................................................. 20Puberty ............................................................................................................................. 21Protective factors: Summary and conclusions ................................................................. 21
Cross-sectional studies of dieting behaviors and eating problems ...................................... 22Longitudinal studies of dieting behaviors and eating problems .......................................... 22
Development of eating problems in children and adolescents......................................... 23AIMS........................................................................................................................................ 24METHOD................................................................................................................................. 25
Designs................................................................................................................................. 25Subjects and procedures....................................................................................................... 26
Study I: A one-year follow-up of eating behaviors and attitudes, dieting and body imagein pre-adolescent girls ...................................................................................................... 26Studies II-V...................................................................................................................... 26Study II: Development of a Swedish version of the Adolescent Coping Orientation forProblem Experiences........................................................................................................ 28Studies III and IV: Dieting behavior, eating attitudes, coping and self-esteem amongadolescent girls over three years ...................................................................................... 29Study V: A longitudinal study of the development of dieting among 7-17 year-oldsSwedish girls .................................................................................................................... 30
Instruments........................................................................................................................... 30The Children's Eating Attitudes Test (ChEAT) ( Studies I,III, IV, V) ............................ 30Demographic and Dieting Questionnaire (Studies, I, III, V) ........................................... 31The Dutch Eating Behavior Questionnaire (DEBQ)(Study IV). ..................................... 31Maus' Body Silhouettes (Study I) .................................................................................... 31Adolescent Coping Orientation for Problem Experiences- Swedish version .................. 31(A-Cope-S)(Studies II, III, IV) ........................................................................................ 31Self-esteem instrument "I Think I Am"(Study IV).......................................................... 32
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Data analyses and statistical methods .................................................................................. 32RESULTS ................................................................................................................................ 33
Summaries of Studies I-V.................................................................................................... 33Study I: A one-year follow-up of eating behaviors and attitudes, dieting and body imagein pre-adolescent girls ...................................................................................................... 33Study II: Development of a Swedish version of the Adolescent Coping Orientation forProblem Experiences........................................................................................................ 34Study III: Dieting, eating attitudes and coping among Swedish adolescent girls: Changesover 3 years. ..................................................................................................................... 35Study IV: Prediction of disturbed eating attitudes in adolescent girls: A 3-yearprospective longitudinal study of eating patterns, self-esteem and coping...................... 36Study V: A longitudinal study of the development of dieting among 7-17 year-oldSwedish girls .................................................................................................................... 37
Future implications and directions....................................................................................... 51Preventive interventions based on empirically sound risk models .................................. 51Suggestions for future research........................................................................................ 52Implications for school health care .................................................................................. 52Implications of present results ......................................................................................... 52Implications of research on preventive efforts................................................................. 53
et al., 1994; Shisslak et al, 1995). Also, as suggested by the McKnight project (Shisslak et al.,
1998b), it is important to identify specific risk and protective factors related to the
development of eating disturbances in order to enable the tailoring of appropriate
interventions to those groups that need them.
It has been suggested (Shisslak 1995) that the results of longitudinal studies can be of great
value when designing prevention programs for specific age-groups, thereby enhancing their
effectiveness in decreasing the number of children and adolescents who engage in dieting and
problematic eating behaviors. Further, it is of great importance to first identify potential risk-
and protective factors that could be related to the onset and maintenance of eating disorders
(Shisslak et al., 1999). The information gained from such studies could be used to design
effective prevention programs for eating disorders as well as eating disturbances that may
serve as precursors to clinical eating disorders (Shisslak et al., 1999).
There are suggestions in the literature that that teaching females to be more critical consumers
of media aimed at beauty and appearance may help prevent the internalization of messages,
and then in turn prevent the development of body dissatisfaction and disturbed eating
behaviors (Berel & Irving, 1998). Further, self-esteem may be enhanced by the experience of
success in a domain that is important to the individual (Shisslak et al., 1998a). Interventions
teaching self-esteem should be conducted with caution since it is crucial that the individual
experiences a feeling of success in order to achieve the desired effect (a boost of self-esteem).
Otherwise, there is a risk of an opposite effect, namely a reduction of self-esteem. Thus,
interventions teaching self-esteem should offer the opportunity of experiencing success in a
domain that is of individual importance. To achieve this it is important to first formulate
individual targets for the experience of success, rather than to employ a pre-determined
52
intervention format in general use in groups of children and adolescents. There is a risk that a
non-specific intervention that is not individually designed, may lead to a drop rather than a
boost in level of self-esteem (Shisslak et al., 1998a).
Research from studies of preventive efforts are so far contradictory. In one study, preventive
efforts have been shown to reduce disturbed eating behaviors and body dissatisfaction during
a short period of time (Moreno & Thelen, 1993). In others, there has been no evident effect at
all (Paxton, 1993; Smolak et al., 1998), or even an increase in eating problems (Carter,
Stweard, Dunn, & Fiarburn, 1997). These results as well as the high cost and relatively low
success rate of treatment for clinical eating disorders lend justification to an investment of
time and resources in research on preventive efforts (Neumark-Sztainer, 1995).
Suggestions for future research
Research is needed to investigate the relationships between coping and eating problems,
preferably by using methodology that can distinguish between mediating and moderating
effects (Baron & Kenny, 1986). This may be of interest since several factors have been
suggested to mediate the relationships between stress and eating pathology (e.g., self-esteem;
Fryer et al., 1997). Future research should focus on distinguishing which precursors are the
strongest predictors, and how these variables interact (Phelps, Johnston & Augustyniak,
1999). This should be conducted through longitudinal studies (Shisslak et al., 1998) with
younger children that can demonstrate causal effects by showing the effects of a specific
event by tracking the course of development (Farrington, 1991). Future studies should also
emphasize the identification of specific risk and protective factors (Shisslak et al 1998b) that
can be effectively modified (Phelps et al., 1999).
Another suggestion for further studies concerns the validity of using self-report/structured
interview methodology among young children, although there are indications that young
children are able to handle these types of questions.
Implications for school health care
Implications of present results
Girls in the present studies (I and III) who report that they have tried to lose weight or are
currently trying to do so, display more disturbed eating attitudes. There was also a stable
pattern of disturbed eating attitudes based on dieting frequency over a three-year period
53
(Study III). Thus, girls who reported dieting behaviors two and three years in a row displayed
more disturbed eating attitudes than their intermittently or non-dieting peers. This was evident
both among 7-8-year olds (Study I) and 13-17 year olds (Study III). Dieting behaviors per se
warrant the attention of school health care providers. The results affirm that simple questions
about weight loss attempts may single out girls at an increased risk of developing more
serious eating disturbances, although the identification of dieting per se will certainly lead to
the identification of a number of false positives. However, this may still be motivated since
questions about dieting behaviors may be a meaningful first screening measure to apply in at-
risk populations in order to reduce the risk of potential eating disturbances. Earlier eating
attitudes, and patterns (restrictive and emotional eating), and possibly self esteem predict
disturbed eating attitudes three years later. Therefore, eating behaviors focusing on healthy
eating and exercise appear to be appropriate targets for school health care interventions. There
were a few correlations between disturbed eating attitudes and lower self-esteem and more
problem behaviors such as staying away from home, smoke and get angry and yell at people.
Although some of these variables did not predict power of disturbed eating attitudes in Year
3, the bivariate correlations should not be dismissed. School health care providers should
focus not only on eating behaviors and dieting, but also on problem behaviors such as
smoking and acting out, since there are indications that such behaviors are related to other
adjustment problems (Wångby et al., 1999) as well as eating disturbances (Fisher et al.,
1991).
Implications of research on preventive efforts
A main limitation of previous preventive interventions has been the sole reliance on didactic
presentations of information with the main focus on apparent risk factors (e.g. concerning
HIV/AIDS, sexual risk behaviors, alcohol and drug use) (Dielman, 1994). However, enhanced
knowledge is not sufficient to change actual behaviors (Dielman, 1994). Based on the present
study and the contradictory results of the research on prevention, we suggest bottom-up
discussions based on the individual's own experiences about issues of bodily changes during
puberty, and the unattainable ideal body shape of contemporary Western society to be
appropriate targets for school interventions. Further, the importance of a high sense of self-
esteem, which may be attained through the experience of success, as well as an adaptive way
of solving everyday problems and managing tension are two other factors that may play a role
in this context. Finally, and above all, the importance of healthy eating patterns for
maintaining a normal body weight and general health status should be stressed. The hazards
54
of dieting and disordered eating may serve as dieting tips (Carter et al., 1997) and should
therefore be avoided.
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ACKNOWLEDGEMENT
I wish to express my deepest gratitude to everyone who has supported me during this work. Iparticularly want to thank the following persons:
First of all, The Girls participating in my studies, their parents, teachers and school-nurses. Withoutyou this thesis would have been impossible to complete.Katarina Lunner, for being both my dearest friend and my exceptionally brilliant colleague! I thankyou for sharing this challenge with me, with all its craziness, laughs and hardships. I also wish toexpress my deepest gratitude for all your encouragement and support, professionally as well aspersonally. You are fabulous, and there is NO WAY I could have done this without you!Per-Olow Sjödén, my supervisor. I thank you for sharing your vast scientific knowledge with me, andfor all your constructive advice. I also thank you for giving me the opportunity to explore a newworld- the world of research and science.Josefin Westerberg, for sticking out with me during all these years that we have been workingtogether. I also thank you for your friendship, fruitful discussions (we would truly make the world abetter place), and for your encouragement during this work.Frida Anteson, for your contributions to the project. I also thank you for all the good chats and foryour encouragement during my work. Jessica Ericsson, my colleague for a year. I thank you for your effort to help bring this ship in toshore.The IDA project advisors for starting the project and making this work possible.IDA "Work-Force", our staff. Thank you for your assistance with interviews and classroomassessments during the data collections. Your work has been essential to the project.Åsa Fichtel, for all your efforts to reduce my stress, and for all chats and nice times.Claudia Lampic, for coaching me through this final stage of this work.My colleagues at the Section for Caring Sciences, I thank you for helping me in various ways.Majbrit Sundelin, Martin Tauman, and Kjell Wetterholm, for valuable administrative support duringmy studies.I wish to express my gratitude to the Faculty of Social Sciences, Uppsala University and The Bank ofSweden Tercentenary Foundation for the financial support during my work.Yvonne Brandberg, for your wisdom and advice during difficult times.Jenny Ekegren and Henrik Söder, for your great generosity. My life as a commuter wouldn't have beenthe same without you. I also wish to thank you for sharing your culinary adventures with me.Eva Hermansson, for always keeping your door open for me, and for sharing your never seizingpositive spirit. I value your friendship.Anna Lii…Sundström, my dearest friend for the past 21 years. I thank you for your friendship, supportand for everything else that we have shared over the years. I also thank you for your specificcontribution to my thesis (check out the cover!).My Mother and Father, Where would I have been without you? I sincerely thank you for all yoursupport and encouragement all through my life.Jenny, for your continuos support and encouragement over the years. Foremost, I thank you for beingmy very special sister.Staffan, My love and my life! I thank you for your patience, your support and encouragement. I alsothank you for always believing in me, and for making me a better person.
Uppsala in October, 2000
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